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  <title>个人中心-个人资料</title>
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<body>
<div class="pusher">
<form method='post' id="form1" name="form1" action="__URL__/usercard"/>
<h4>我的入驻资金：100元</h4>
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            <div class="form example" data-use-content="true">

                <div class="ui form">


                  
                    <div class="field">
                        <label>店铺名称</label>
                        <input value="" name="dian" type="text">
                    </div>
                     <div class="field">
                        <label>联系电话</label>
                        <input value="" name="tel" type="text">
                    </div>                   
                      <div class="field">
                        <label>申请级别</label>
                         <input type="radio" value="1" name="daili">县级代理
                         <input type="radio" value="2" name="daili">市级代理
                         <input type="radio" value="3" name="daili">省级代理
                     </div>
                      <div class="field">
                         <input type="checkbox" value="服务" checked="checked" name="ids" style="margin-top:5px;">
                         我已同意《晋商农场主入驻协议》 
                     </div>
                    <div class="button"><input name="submit1" id="Access" type="submit" value="提交" class="ui red submit mini btn"  /></div>
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  </form>     
</div>
<include file="Public:footer" />